A ‘natural experiment’ to measure hospice cost change

To improve on prior estimates of the cost of hospice expansion to Medicare, the researchers employed a methodology in which they could assess the effect of hospice becoming more available to those who actually would prefer it.

PROVIDENCE, R.I. [Brown University] — Prior “observational” studies have attempted to estimate — with mixed results — whether hospice increases Medicare costs by comparing costs for nursing home residents who elected hospice and those who didn’t in the same timeframe or cohort. But that approach is flawed, said Brown University public health researcher Pedro Gozalo, because it doesn’t account for patients’ preferences regarding care.

When the goal is to measure the net additional cost of increased hospice use, what must be compared is the cost incurred by someone who wanted hospice and got it, with the cost incurred by someone who did not want aggressive end-of-life care but didn’t get hospice.

After hospice became more widely available, as it did after expansion, patients that did not elect hospice in a given year probably had a higher preference for aggressive care. They therefore are not an ideal group to compare to those that elected hospice that year. Going back in time to 2004, when hospice was not as pervasive an option, gave the researchers a “natural experiment.” They could find individuals who did not want aggressive end-of-life care but did not get hospice and comparing them to individuals in 2009 who also did not want aggressive care but got hospice.

So the researchers amassed data to yield a group of “new” hospice users consisting of decedents who used hospice in 2009 but would not have been likely to elect hospice in 2004, and compared their outcomes to those of similar decedents in 2004 who did not use hospice but likely would have done so had it been more readily available. To account for changes over time due to other trends rather than due to changes in hospice election, the researchers compared the changes in outcomes over time for this new hospice comparison group to those that occurred for a group of decedents who did not use hospice, and likely didn’t want to, in either year.

The result was a view of how service use and costs rose in groups of patients with comparable care preferences. As hospice expanded, costs rose as more patients who wanted palliative care, but did not want intensive care, received what they preferred.

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